Hospital-acquired infections have emerged as one of the most important public health challenges over the past few years. The Pennsylvania Health Care Cost Containment Council (PHC4) contributed to the body of knowledge about the significant impact of these infections when it began publicly reporting actual statewide numbers in July 2005.
Hospital-acquired infections represent a direct threat to patient safety and health care quality. Hospital-acquired infections, in the aggregate, have a significant overall impact upon the cost of care, as well as on patient care outcomes and should not be dismissed as an inevitable risk.
This publication, which is PHC4’s second hospital-specific report, can be useful for health care consumers and purchasers in evaluating the quality of care, and for hospitals and clinicians in improving the quality of care. It also can help initiate discussions between patients and their doctors and nurses, and serve as a tool among hospital providers about what needs to be done to eliminate infections and improve health care quality.
It is important to point out that the collection and reporting of hospital-acquired infection data is still evolving. As Pennsylvania was the first state in the nation to report this information, there is little, if any, comparative information by which one can evaluate infection patterns and trend data. In addition to reporting all four quarters of the most recent data–calendar year 2006, this report provides some limited comparative information by displaying the two most similar data collection time periods: Quarter 4, 2005 and Quarter 4, 2006. Over time, Pennsylvania's reports will be able to provide more detailed comparative information as part of a broader process of evaluating interventions and best practices in order to prevent and control infections. Currently, however, this cannot be accomplished by comparing the entirety of calendar years 2005 and 2006, due to the expansion of reporting requirements over that time period, as well as improvements in hospital reporting.
This report should be used to measure individual hospital performance over time, rather than to compare hospitals to each other. It should be used as a tool to ask physicians and hospital representatives informed questions, especially about infection control and prevention. It is not intended to be the sole source of information in making decisions about hospital care, nor should it be used to generalize about the overall quality of care provided by hospitals. The measurement of quality is highly complex, and the information used to capture such measures is limited.
Within this report, differences in mortality, length of stay and hospital charges can be observed among patients with and without a hospital-acquired infection. For example, the mortality rate for patients with a hospital-acquired infection was 12.3%, while the mortality rate for patients without a hospital-acquired infection was 2.1%. The mean length of stay for patients with a hospital-acquired infection was 19.3 days, while the mean length of stay for patients without a hospital-acquired infection was 4.4 days. The median length of stay for patients with a hospital-acquired infection was 14.0 days, while the median length of stay for patients without a hospital-acquired infection was 3.0 days. The mean total hospital charge for patients with a hospital-acquired infection was $175,964, while the mean for those patients without such infections was $33,260. The median total hospital charge for patients with a hospital-acquired infection was $79,670, while the median for those patients without such infections was $18,538. The mean total commercial insurance payment for a case with a hospital-acquired infection was $51,096, while the mean total payment for a case without one was $9,181. The median total commercial insurance payment for a case with a hospital-acquired infection was $24,027, while the median total payment for a case without one was $5,440. The payment figures do not include Medicare or Medicaid.
It is important to note that the degree to which the presence of hospital-acquired infections influenced these numbers is unknown. Some of the differences in mortality, lengths of stay and charges may be influenced by other factors, including the complex medical needs of the patient that necessitated hospitalization. Hospitals and physicians may do everything right and still, a hospital death or complication can be an unavoidable consequence of a patient’s medical condition. Where hospital charges are concerned, in almost all cases, hospitals do not receive full charges from private insurance carriers or government payors. In fact, on an average basis, across all inpatient hospital cases statewide (not just infection cases), hospitals are reimbursed or paid for approximately 27% of established charges.*
Several studies published in the November 2006 issue of the American Journal of Medical Quality challenged the idea that infections are driven primarily by patient risk factors or severity of illness levels, as opposed to improper hand hygiene or other inconsistencies in the best practice applications of infection prevention and control. One study in particular (Johannes et al., 2006) concluded that the variations in mortality, length of hospitalization, and hospital charges observed in the 2004 hospital-acquired infection data could not be explained by differences in severity of illness. While the additional mortality, length of stay, and additional charges for patients with a hospital-acquired infection as compared to patients without a hospital-acquired infection may not be entirely attributable to those infections, it is reasonable to assume that infections are a contributing factor to these differences. The debate over the role of risk factors in the contraction of a hospital-acquired infection is certain to continue, and further study is warranted.
Many hospital-acquired infections can be prevented. There are simple and effective methods that can dramatically reduce the incidence of hospital-acquired infections: hand washing; using gloves and properly sterilized equipment; and following evidenced-based best practices every time, all the time, for procedures like the insertion of an intravenous catheter to deliver fluids and medication.
Patients also can play a role by becoming informed consumers and advocates for stellar care. Wash your hands. Make sure your health care providers and hospital visitors have washed theirs as well. And ask questions of your doctors and hospital about their infection control processes.
This is Pennsylvania’s second hospital-specific report on hospital-acquired infections. The format of this second report has been modified due to changes in hospital reporting requirements from 2005 to 2006 and to give readers, as much as possible, an “apples-to-apples” comparison between the two years of data. The reader should not make any direct comparisons of overall numbers, or draw conclusions about the reported differences because 2006 was the first year in which all hospital-acquired infections were required to be reported to PHC4.
The first report released in November 2006 represented a snapshot of activity over a one-year period (calendar year 2005). It included hospital-acquired infections identified, confirmed and submitted by Pennsylvania hospitals for the following categories: central line-associated bloodstream infections, ventilator-associated pneumonia, indwelling catheter-associated urinary tract infections and surgical site infections for circulatory, neurological and orthopedic procedures. For the third and fourth quarters of 2005, the surgical site infection category was expanded to include all surgical procedures. For the fourth quarter of 2005, the pneumonia, bloodstream and urinary tract infection categories were expanded to include hospital-acquired infections that were not device-related. As of January 2006, the phase-in of reporting requirements was complete, and Pennsylvania hospitals were required to submit data on all hospital-acquired infections to PHC4.
With this second report, PHC4 had originally intended to show the most current one-year period of data (calendar year 2006). However, since it was likely that readers would compare 2005 to 2006 totals which cannot be done because of the phased-in reporting requirements, the decision was made to essentially create two reports in one.
Hospital-specific information for all of 2006 is presented in one section, while a comparison of each hospital's Quarter 4, 2005 and Quarter 4, 2006 numbers is displayed in another. Quarter 4, 2005 and Quarter 4, 2006 are the two quarters for which the reporting requirements were the most alike. Still, the Council has repeatedly stressed that trending over time, and not a single one-year snapshot, will be most instructive because the ultimate goal shared by all is the reduction in occurrence of these infections.
PHC4 does not use billing data to identify hospital-acquired infections; the hospital-acquired infections listed were identified, confirmed and submitted by Pennsylvania hospitals. To define a hospital-acquired infection, PHC4 adopted the Centers for Disease Control and Prevention (CDC) definition: an infection is a localized or systemic condition that 1) results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and 2) was not present or incubating at the time of admission to the hospital. In simple terms, patients did not have it when they entered the hospital, and they contracted it while they were there.
PHC4 also adopted, with minor adjustments, the CDC's 13 major site categories that define the hospital-acquired infection location, and expanded the list of 13 to include a category for multiple infections and to differentiate device related and non-device related infections. PHC4 then redefined a two-character data field (Field 21d) on the Pennsylvania Uniform Claims and Billing Form, which is submitted along with administrative and billing data for each inpatient hospital admission. Hospital personnel enter one of a defined set of codes into this field when the relevant hospital-acquired infection is present.
Hospitals differ in terms of the volume and types of care provided, and the completeness of infection reporting may vary across hospitals and maybe even within the same hospital. For example, a low number of infections reported by a hospital could mean that it is doing an excellent job in reducing its infection rate and ensuring patient safety. On the other hand, it could indicate the hospital is underreporting its infection numbers to PHC4. Conversely, a hospital with a high number of infections might appear to be less effective at patient safety. Yet, in reality, it may be doing a very good job of identifying and reporting infections. Hospitals using electronic surveillance approaches may report higher numbers for this reason, and these hospitals are noted in the report.
Pennsylvania hospitals are making every effort to comply with the hospital-acquired infection reporting requirements; however, some data submission disparities among hospitals still exist, and some underreporting may be occurring. During the past two years, PHC4 has undertaken a series of independent audits of Pennsylvania hospitals to evaluate the accuracy of the reporting, and the most recent audits have demonstrated noticeable improvement.
The national discussion regarding the public reporting of hospital-acquired infection data has included an ongoing debate about how, or whether, to risk-adjust this information. That is, should patient characteristics, including the presence of other diseases or conditions, along with how ill the patient is, be considered when analyzing the data? PHC4's Technical Advisory Group has had discussion and has looked at detailed data analysis in considering this issue of risk-adjustment. One argument against risk-adjusting hospital-acquired infection data is that we should all strive toward the goal of zero hospital-acquired infections. The reporting of actual numbers, rather than risk-adjusted numbers, highlights actual results and encourages root cause analysis of every patient who contracted an infection while in the hospital.
For purposes of this report, PHC4 is presenting actual numbers of infections. The report does recognize that certain patients may be at greater risk for the development of infections, including patients being treated for burns, undergoing organ transplants, or being treated for complications of an organ transplant. These patients are excluded from the report because they are at a significantly greater risk of acquiring an infection while in a hospital. It would be unfair to list hospitals specializing in these conditions alongside those who treat few or no patients with these conditions if these cases were included. PHC4 also decided to present the data by hospital peer groups, in which hospitals that offer similar types and complexity of services and treat similar numbers of patients are displayed together.
The debate about the relationship of patient risk factors and characteristics to hospital-acquired infections will certainly continue, and PHC4 intends to follow and contribute to this dialogue.
This report includes information on 1,574,170 patients treated in the 165 Pennsylvania general acute care hospitals during calendar year 2006. Information was provided on cases for which the hospital was required to report hospital-acquired infections, which includes patients that were at least two years old and were hospitalized for reasons other than mental disorders or alcohol and drug related disorders. Patients that were hospitalized for an organ transplant, complications of an organ transplant, and/or burn treatment were not included in the report.
The following information is presented for cases in the report:
Number of Cases - The number of cases with infections represents the hospital-acquired infections identified and reported by the hospital.
Infection Rate - This is the rate of infection per 1,000 cases. The rate is based on the number of patients for which hospitals were required to report hospital-acquired infections, with one exception. For surgical site infections, only patients undergoing surgical procedures were included.
Mortality - The number and percent of mortality represents the number/percent of patients who died during the hospitalization. It is important to note that the cause of death may not have been related to the hospital-acquired infection.
Mean and Median Length of Stay and Hospital Charge - Both the mean and the median are averages. The mean length of stay represents the number of days a patient would have been in the hospital, if all patients had an equal length of stay. The mean charge represents the amount that a patient would have been charged for their hospital care, if all the patients had equal charges. The mean is the measure most often referred to as the average. The median length of stay represents the midpoint of all the lengths of stay for all patients in a particular hospital. In other words, half of the stays are longer in length than the median and half are shorter in length than the median. The median charge represents the midpoint of all charges for all the patients in a particular hospital. In other words, half of the charges are more than the median and half are less than the median. Both the mean and the median include extreme values, also known as outliers. Because outliers have more of an effect on the mean than the median, the mean offers greater insight regarding the presence of extreme lengths of stay or charges. On the other hand, the median offers greater insight into mid-range lengths of stay or charges.
Neither mean nor median hospital charges include professional fees (e.g., physician fees) and do not reflect the amount that a hospital is actually reimbursed. Generally, hospitals do not receive full reimbursement of charges because insurance companies and other large purchasers of health care usually negotiate large discounts.
The four peer groups identified in this report were developed to assist the reader in recognizing “like” hospitals. Hospitals were grouped according to the complexity of services offered, the number of patients treated, and the percent of surgical procedures performed. Unlike the first report, hospitals using electronic hospital-acquired infection surveillance were not separated out from their respective peer group; they were, however, noted as using electronic surveillance.
Peer Group 1 includes hospitals that provide more complex services and treat a larger number of patients than Peer Groups 2, 3, and 4. Hospitals that are designated as trauma centers were included in this group. All of the hospitals in Peer Group 1 perform open-heart surgery. They treat an average of 25,430 patients a year. On average, 39 percent of these patients undergo surgical procedures.
Peer Group 2 includes hospitals that provide more complex services and treat a larger number of patients than Peer Groups 3 and 4. All of the hospitals in Peer Group 2 perform open-heart surgery. They treat an average of 11,000 patients a year. On average, 34 percent of these patients undergo surgical procedures.
Peer Group 3 includes hospitals that treat a larger number of patients than Peer Group 4. They treat an average of 7,400 patients a year. On average, 24 percent of these patients undergo surgical procedures.
Peer Group 4 hospitals treat an average of 1,950 patients a year. On average, 18 percent of these patients undergo surgical procedures.
Infection surveillance is the process used within hospitals to identify those patients who might either have entered the hospital with an infection or who may have acquired an infection while hospitalized, as well as to assess disease outbreaks that might occur within a health care facility. Traditional infection surveillance is a time-consuming process; infection control staff must review numerous reports generated by different departments within the hospital in order to identify hospital-acquired infections, infection trends, and other issues. As a result, “targeted” surveillance has often been used.
Over the last several years, hospitals have started to consider how the surveillance process can be automated to assist infection control professionals in this important job. Electronic surveillance systems enable integration of data from multiple departments, assist in fast identification of patients with an infection or at risk for an infection, and improve the productivity of the infection control staff, thus allowing greater time for professional and patient education on infection prevention.
Electronic surveillance systems assist in reviewing laboratory, pharmaceutical, and radiology information. Because the data is available in real time, facilities can reduce preventable infections, improve safety, decrease costs, and report infections more accurately.
During the period covered by this report, 13 hospitals were using a form of electronic surveillance software for at least one quarter to identify hospital-acquired infections. The extent to which a hospital utilizes their electronic surveillance software to submit hospital-acquired infection data to PHC4 varies. Some facilities may use the electronic surveillance software as a screening tool only. That is, cases flagged by the electronic surveillance software as having a potential hospital-acquired infection are reviewed by an infection control professional, who makes the final determination of whether or not a hospital-acquired infection is present.
Hospitals using electronic surveillance software were listed in their respective peer group. These facilities were identified with a notation made for the first quarter in which the electronic surveillance software was used. This notation was made to alert the reader that in the instances where higher numbers of infections were reported, this may be due to more comprehensive reporting, and not that these hospitals have, in reality, a higher infection rate than facilities not using such strategies. Over time, it will become clearer as to whether differences reported are due to higher infection rates or better identification and reporting of infections.
PHC4 wishes to acknowledge and thank the many infection control professionals, medical records staff, and infectious disease physicians for their commitment to this process and their dedication to providing the highest quality care possible to all Pennsylvanians. PHC4 also wishes to thank its Technical Advisory Group for their invaluable assistance.
The American Hospital Association, the American Medical Association and the National Patient Safety Foundation offer the following action steps for patients to take while hospitalized:
There are many initiatives underway in Pennsylvania to address the issue of hospital-acquired infections including the Institute for Healthcare Improvement campaign, the National Surgical Care Improvement campaign, the Pittsburgh Regional Health Initiative and the Partnership for Patient Safety in southeastern Pennsylvania, among others. Please visit the PHC4 website — http://www.phc4.org — for more information.
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